Payment for Moderate Sedation Services Furnished with ...

1 Page 1 of 2 Payment for Moderate Sedation Services Furnished with colorectal cancer screening Tests MLN Matters Number: MM10075 Related CR Release Date: April 28, 2017 Related CR Transmittal Number: R3763CP Related Change Request (CR) Number: 10075 Effective Date: January 1, 2017 Implementation Date: October 2, 2017 PROVIDER TYPE AFFECTED This MLN Matters a rticle is intended for physicians and other providers submitting claims to Part A and B Medicare Administrative Contractors (MACs) for Sedation Services Furnished with colorectal cancer screening tests. PROVIDER ACTION NEEDED Change Request (CR) 10075 ensures accurate program Payment for Moderate Sedation Services Furnished in conjunction with screening colonoscopy Services for which the beneficiary should not be charged the coinsurance or deductible.

2 The coinsurance and deductible for these Services are waived, but due to coding changes and additions to the Medicare Physician Fee Schedule (MPFS) Database the payments for Calendar Year (CY) 2017 would not be accurate without this CR. Please make your billing staff aware of these changes. BACKGROUND Section 4104 of the Affordable Care Act defined the term preventive Services to include colorectal cancer screening tests and, as a result, it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Social Security Act for screening colonoscopies. In addition, the ACA amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies, which includes Moderate Sedation Services as an inherent part of the screening colonoscopy procedural service.

3 These provisions are effective for Services Furnished on or after January 1, 2011. In the CY 2017 PFS Final Rule, the Centers for Medicare & Medicaid Services (CMS) modified coding and reporting of procedural Services that include Moderate Sedation as an inherent part of the service, including for screening colonoscopies. CR 10075 operationalizes the existing waiver of deductible and coinsurance for Moderate Sedation Services Furnished in conjunction with and in support of colorectal cancer screening tests. Effective January 1, 2017, beneficiary MLN Matters MM10075 Related CR10075 Page 2 of 2 coinsurance and deductible continues to not apply to the following Moderate Sedation claim lines when Furnished in conjunction with screening colonoscopy Services and when billed with Modifier 33 or Modifier PT: HCPCS code G0500: Moderate Sedation Services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that Sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient s level of consciousness and physiological status.

4 Patient age 5 years or older (additional time may be reported with 99153, as appropriate). CPT code 99153: Moderate Sedation Services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the Sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in addition to code for primary service). MACS will not search their files to either retract Payment for claim lines already paid or to retroactively pay claim lines with HCPCS code G0500 or CPT code 99153. However, MACs will adjust such claims that you bring to their attention.

5 ADDITIONAL INFORMATION The official instruction, CR10075, issued to your MAC regarding this change is available at If you have any questions, please contact your MAC at their toll-free number. That number is available at DOCUMENT HISTORY Date of Change Description May 1, 2017 Initial article released Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

6 CPT only copyright 2016 American Medical Association. All rights reserved.